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Benign Prostatic Hyperplasia


Benign prostatic hyperplasia which is often loosely interchanged with benign prostatic hypertrophy ( even  among urologists) is the commonest cause of prostate enlargement. It is also often abbreviated as BPH. This condition is particularly common among men over the age of 45 ( because of the second prostate growth spurt which commences during the fifth decade of life) and the incidence increases with age thereafter. It is estimated that by the eight decade of life, about 90 percent of men have hyperplasia of   the prostate which is often discovered at autopsy. The disorder occurs in all populations, but it has been found to occur less frequently in Oriental population. The symptoms of benign prostatic hyperplasia occurs earlier in blacks ( mean age = 60 years) than whites ( mean age = 65 years). This condition is the commonest cause of obstruction to urinary outflow in men. It has not yet been established whether hyperplasia predisposes to the development of  prostatic cancer.

Causes Of Enlarged Prostate

Causes Of Enlarged Prostate

Symptoms Of Enlarged Prostate
Benign Prostatic Hyperplasia
Prostatic Carcinoma

Prostatitis
Benign Prostatic Hyperplasia (BPH)
The hyperplasia begins in the prostate tissue around the urethra and then progresses to compress the remaining gland. The tissue becomes nodular, comprising of smooth muscle, stroma and glandular epithelium. The precise reason for the proliferation of the glandular epithelium is not known, however, the involvement of Androgen (testosterone and other male hormones) estrogens and other growth factors have been postulated. The prostate lies between the bladder ( and surrounds the urethra) and the rectum, therefore, the enlargement can obstruct urinary outflow causing urinary retention or obstruct the rectum causing constipation and consequently, may be associated with abdominal pain.

Symptoms Of Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia causes both obstructive and irritative symptoms. Obstructive symptoms are related to the mechanical obstruction of the urethra by the enlarged prostate (intially, the bladder tries to overcome the obstruction by undergoing a compensatory hypertrophy), while irritative symptoms result from contraction of the bladder detrusor muscle. Both symptoms are associated together, 50 percent of the times. Sometimes, an individual may have BPH without any symptoms.

Obstructive Symptoms:
The obstructive symptoms include: hesitancy ( difficulty in initiating the flow of urine), diminished force of urinary stream (despite a full bladder), feeling of incomplete bladder emptying ( patient feels that there is still some residual urine), intermittent urinary stream, straining to urinate, Post-urination urinary dribbling ( ranging from a couple of drops after urination to a continuous leak that is difficult to control) and urinary retention ( this retention may occur suddenly or over a period of time).

Irritative Symptoms:
The irritative symptoms include: daytime frequency, nocturia (awakening from sleep to pass urine at night), dysuria (painful or difficult urination), urgency (sudden, compelling urge to urinate that brooks no delay), and overflow or urge incontinence ( an urgent need to urinate that may be associated with leakage of urine).

If the condition becomes complicated, there may be hematuria (presence of blood in the urine) due to congestion and rupture of the superficial veins of the prostatic urethra. Straining to urinate may eventually lead to syncope (vasovagal), inguinal hernias. Other symptoms may also include abdominal discomfort and urinary retention. Urinary retention can either be chronic ( developing over time) or acute ( occurring suddenly). Acute urinary retention can be precipitated by infections, alcohol, anesthetics, exposure to cold or use of antihistamines.

Management Of Benign Prostatic Hyperplasia

Diagnosis Of BPH

Diagnosis of the condition is based principally on digital rectal examination and the symptoms that the patient present with. Digital rectal examination may reveal an enlarged prostate with or without a palpable bladder. The natural history of the condition is not often clear cut and a majority of men with BPH do not present with either significant obstructive or irritative symptoms, and an enlargement of the prostate alone is not always a valid reason to treat the affected individual.

The attending health practitioner will take a detailed history, focusing on the urinary tract, making every effort to identify or rule-out other possible causes of urinary voiding dysfunction. The practitioner may quantify the disorder ( as either mild, moderate, or severe) based on AUA Symptom index ( which is also used in planning treatment and patient follow-up). Prostate-specific antigen ( PSA) may be measured and used for exclusion of advanced cases on prostate cancer. PSA is not particularly useful in early case of Prostate cancer. Other tests that may be carried out include uroflowmetry, postvoid residual urine volume, pressure-flow studies, urethrocystoscopy and imaging studies such as ultrasonography and intravenous pyelography. The health practitioner will determine which is appropriate.

Treatment Of BPH

Patients who have benign prostatic hyperplasia but do not have any symptom, are generally not placed on any treatment. A variety of decision diagrams are available to assist health practitioners in making decisions as to what kind of action is applicable, but ultimately, the decision to treat and the appropriate treatment depends on the severity ( and type) of the symptoms and affected individual's expectations and preparedness to accept the adverse consequences of treatment

  Lifestyle Modification: Affected individuals are advised to decrease fluid intake before bedtime, reduce consumption of alcohol or caffeinated beverages.
   
  Watchful Waiting: This approach is for individuals who do not have symptoms. But these individuals must be monitored annually for evidence of disease progression.  
 

Before engaging in any form of medical or surgical intervention for BPH,  the health practitioner will perform the following: Take a complete history, perform a thorough physical examination which includes a digital rectal examination, ultrasound, routine urine analysis, electrolyte check, determination of post-voidal residual urine, cystoscopy and PSA determination.

 
 

Medical Treatment: Medical treatment is targeted towards relaxing the prostatic smooth muscles ( by inhibiting the alpha adrenergic receptors) and suppression of the hormones. Fenastride is the most promising of the anti-androgenic drugs that are currently in use. This drug inhibits 5-alpha reductase enzyme and thereby blocking the conversion of testosterone to dihydrotestosterone. It has been shown to reduce the prostate size by about 24 percent, the PSA levels and consequently an improvement in the symptoms.  Terazosin has been effectively used to relax the smooth muscle of the bladder neck and therefore increased urinary flow rate. Not all affected individuals respond to medical treatment and the drugs also have their own side effects which we will not discuss here.

   
  Surgery: Prostate surgery provides the best chance of improvement in symptoms, but it also comes with possible complications. In general, transurethral resection of the prostate is the most common surgical method in use. This the ideal procedure used for patients with relatively small prostates. Open prostatectomy is used on affected individuals with huge prostate. Open prostatectomy has high complication rates.

Other methods of treatment such as laser surgery., thermal therapy and stents are also being evaluated for efficacy. But the health practitioner will make the decision as to which line of action is appropriate for you. Be sure to consult your doctor for clarification.


References

http://www.merck.com/mmpe/sec17/ch240/ch240b.html

Benign prostatic hyperplasia - From Wikipedia, the free encyclopedia Retrieved on 103009

Bent S, Kane C, Shinohara K, et. al. Saw palmetto for benign prostatic hyperplasia. NEJM . 2006; 354:557-566.

Wilt, T.J., et al. Saw Palmetto extracts for treatments of benign prostatic hyperplasia. Journal of the American Medical Association 1998; 280: 160-9

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